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Department of Internal Medicine

Cardiovascular Health and Disease

Photo of  Andrew Burger, MD

Andrew Burger, MD

Professor of Medicine; Associate Director, Cardiovascular Disease Fellowship Program

Education/Credentials
  • Medical Degree: University of Pittsburgh
  • Residency-Internal Medicine: University of Connecticut Health Center
  • Fellowship-Cardiovascular Disease: University of Connecticut Health Center

Research/Clinical Interests

Clinical Interests: Noninvasive cardiology, Heart failure, Echocardiography, Nuclear cardiology. Research Interest: Heart failure

Board Certifications & Licenses
  • National Board of Medical Examiners, 1979
  • Connecticut License Registration, 1980
  • Certificate American Board of Internal Medicine, 1982
  • West Virginia License Registration, 1983
  • Certificate, Subspeciality of Cardiovascular Disease American Board of Internal Medicine, 1985
  • Ohio License Registration, 2007
Contact Information
  • Medical Sciences Building
  • 231 Albert Sabin Way, MLC 0542
  • Cincinnati, Ohio 45267
  • Office 513-558-3566
  • Fax 513-558-2884
  • Email andrew.burger@uc.edu

Peer Reviewed Publications

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Aronson, Doron; Burger, Andrew J 2015. Diuretic Response: Clinical and Hemodynamic Predictors and Relation to Clinical Outcome. Journal of cardiac failure, ,

Halperin, Jonathan L; Hankey, Graeme J; Wojdyla, Daniel M; Piccini, Jonathan P; Lokhnygina, Yuliya; Patel, Manesh R; Breithardt, Günter; Singer, Daniel E; Becker, Richard C; Hacke, Werner; Paolini, John F; Nessel, Christopher C; Mahaffey, Kenneth W; Califf, Robert M; Fox, Keith A A 2014. Efficacy and safety of rivaroxaban compared with warfarin among elderly patients with nonvalvular atrial fibrillation in the Rivaroxaban Once Daily, Oral, Direct Factor Xa Inhibition Compared With Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF). Circulation, 130 2, 138-46

Aronson, Doron; Abassi, Zaid; Allon, Eyal; Burger, Andrew J 2013. Fluid loss, venous congestion, and worsening renal function in acute decompensated heart failure. European journal of heart failure, 15 6, 637-43

Solomonica, Amir; Burger, Andrew J; Aronson, Doron 2013. Hemodynamic determinants of dyspnea improvement in acute decompensated heart failure. Circulation. Heart failure, 6 1, 53-60

Nearing, Bruce D; Mittleman, Murray A; Josephson, Mark E; Verrier, Richard L; Wellenius, Gregory A; Burger, Andrew J 2012. Response to letter regarding article, "crescendo in depolarization and repolarization heterogeneity heralds development of ventricular tachycardia in hospitalized patients with decompensated heart failure". Circulation. Arrhythmia and electrophysiology, 5 3, e79

Nearing, Bruce D; Wellenius, Gregory A; Mittleman, Murray A; Josephson, Mark E; Burger, Andrew J; Verrier, Richard L 2012. Crescendo in depolarization and repolarization heterogeneity heralds development of ventricular tachycardia in hospitalized patients with decompensated heart failure. Circulation. Arrhythmia and electrophysiology, 5 1, 84-90

Aronson, Doron; Eitan, Amnon; Dragu, Robert; Burger, Andrew J 2011. Relationship between reactive pulmonary hypertension and mortality in patients with acute decompensated heart failure. Circulation. Heart failure, 4 5, 644-50

Lather, Navneet; Efeovbokhan, Nephertiti; Hakeem, Abdul; Kotaru, Pavan; Abela, George S; Burger, Andrew J; Rubinstein, Jack 2011. Advanced echocardiographic imaging to predict exercise capacity in relatively healthy women. International journal of cardiology, 151 3, 369-71

Aronson, Doron; Burger, Andrew J 2010. The relationship between transient and persistent worsening renal function and mortality in patients with acute decompensated heart failure. Journal of cardiac failure, 16 7, 541-7

Burger, Andrew J; Han, Yuchi; Aronson, Doron 2009. The relationship between body mass index and mortality in patients with acute decompensated heart failure. International journal of cardiology, 134 1, 132-5

Lumley, Mark A; Cohen, Jay L; Stout, Rebecca L; Neely, Lynn C; Sander, Lindsay M; Burger, Amanda J 2008. An Emotional Exposure-Based Treatment of Traumatic Stress for People with Chronic Pain: Preliminary Results for Fibromyalgia Syndrome. Psychotherapy (Chicago, Ill.), 45 2, 165-172

Lumley, Mark A; Neely, Lynn C; Burger, Amanda J 2007. The assessment of alexithymia in medical settings: implications for understanding and treating health problems. Journal of personality assessment, 89 3, 230-46

Weinrauch, Larry A; Burger, Andrew J; Aepfelbacher, Franz; Lee, Annette T; Gleason, Ray E; D'Elia, John A 2007. A pilot study to test the effect of pulsatile insulin infusion on cardiovascular mechanisms that might contribute to attenuation of renal compromise in type 1 diabetes mellitus patients with proteinuria. Metabolism: clinical and experimental, 56 11, 1453-7

Burger, A J; Burger, M R 2005. Nesiritide: past, present, and future. Minerva cardioangiologica, 53 6, 509-22

Burger, Andrew J 2005. Risk of death with nesiritide. JAMA : the journal of the American Medical Association, 294 8, 897; author reply 89

Burger, Andrew J; Tsao, Lana; Aronson, Doron 2005. Prognostic impact of diabetes mellitus in patients with acute decompensated heart failure. The American journal of cardiology, 95 9, 1117-9

Kirtane, Ajay J; Leder, David M; Waikar, Sushrut S; Chertow, Glenn M; Ray, Kausik K; Pinto, Duane S; Karmpaliotis, Dimitrios; Burger, Andrew J; Murphy, Sabina A; Cannon, Christopher P; Braunwald, Eugene; Gibson, C Michael 2005. Serum blood urea nitrogen as an independent marker of subsequent mortality among patients with acute coronary syndromes and normal to mildly reduced glomerular filtration rates. Journal of the American College of Cardiology, 45 11, 1781-6

Aepfelbacher, Franz C; Yeon, Susan B; Weinrauch, Larry A; D'Elia, John; Burger, Andrew J 2004. Improved glycemic control induces regression of left ventricular mass in patients with type 1 diabetes mellitus. International journal of cardiology, 94 1, 47-51

Akhter, Mohammed W; Aronson, Doron; Bitar, Fahed; Khan, Salman; Singh, Harpreet; Singh, Rajinder P; Burger, Andrew J; Elkayam, Uri 2004. Effect of elevated admission serum creatinine and its worsening on outcome in hospitalized patients with decompensated heart failure. The American journal of cardiology, 94 7, 957-60

Aronson, Doron; Burger, Andrew J 2004. Effect of nesiritide (human b-type natriuretic peptide) and dobutamine on heart rate variability in decompensated heart failure. American heart journal, 148 5, e16

Aronson, Doron; Burger, Andrew J 2004. Prognosis assessment in patients with decompensated heart failure. Simple clinical parameters or neurohormonal factors. Italian heart journal : official journal of the Italian Federation of Cardiology, 5 7, 494-7

Aronson, Doron; Burger, Andrew J 2004. Relation between pulse pressure and survival in patients with decompensated heart failure. The American journal of cardiology, 93 6, 785-8

Aronson, Doron; Mittleman, Murray A; Burger, Andrew J 2004. Elevated blood urea nitrogen level as a predictor of mortality in patients admitted for decompensated heart failure. The American journal of medicine, 116 7, 466-73

Aronson, Doron; Mittleman, Murray A; Burger, Andrew J 2004. Measures of heart period variability as predictors of mortality in hospitalized patients with decompensated congestive heart failure. The American journal of cardiology, 93 1, 59-63

Aronson, Doron; Burger, Andrew J 2003. Neurohumoral activation and ventricular arrhythmias in patients with decompensated congestive heart failure: role of endothelin. Pacing and clinical electrophysiology : PACE, 26 3, 703-10

Aronson, Doron; Burger, Andrew J 2003. Neurohormonal prediction of mortality following admission for decompensated heart failure. The American journal of cardiology, 91 2, 245-8

Aronson, Doron; Mittleman, Murray A; Burger, Andrew J 2003. Effects of sulfonylurea hypoglycemic agents and adenosine triphosphate dependent potassium channel antagonists on ventricular arrhythmias in patients with decompensated heart failure. Pacing and clinical electrophysiology : PACE, 26 5, 1254-61

Burger, Andrew J; Aronson, Doron; Horton, Darlene P; Burger, Mary R 2003. Comparison of the effects of dobutamine and nesiritide (B-type natriuretic peptide) on ventricular ectopy in acutely decompensated ischemic versus nonischemic cardiomyopathy. The American journal of cardiology, 91 11, 1370-2

Burger, Andrew J; Silver, Marc A 2003. Nesiritide in acute heart failure. Lancet, 362 9388, 998; author reply 99

de Lissovoy, Gregory; Stier, David M; Ciesla, Gabrielle; Munger, Mark; Burger, Andrew J 2003. Economic implications of nesiritide versus dobutamine in the treatment of patients with acutely decompensated congestive heart failure. The American journal of cardiology, 92 5, 631-3

Aronson, D; Burger, A J 2002. Diabetes and the occurrence of ventricular arrhythmic events in patients with severe left ventricular dysfunction. Diabetologia, 45 10, 1440-5

Aronson, Doron; Burger, Andrew J 2002. Intravenous nesiritide (human B-type natriuretic peptide) reduces plasma endothelin-1 levels in patients with decompensated congestive heart failure. The American journal of cardiology, 90 4, 435-8

Aronson, Doron; Burger, Andrew J 2002. The effect of sex on ventricular arrhythmic events in patients with congestive heart failure. Pacing and clinical electrophysiology : PACE, 25 8, 1206-11

Aronson, Doron; Burger, Andrew J 2002. Concomitant beta-blocker therapy is associated with a lower occurrence of ventricular arrhythmias in patients with decompensated heart failure. Journal of cardiac failure, 8 2, 79-85

Burger, Andrew J; Al-Sergani, Hani; Wrobleski, David 2002. False positive ST segment elevation during dobutamine stress echocardiography due to left ventricular hypertrophy. Echocardiography (Mount Kisco, N.Y.), 19 2, 103-8

Burger, Andrew J; Aronson, Doron 2002. Age and sex as determinants of ventricular arrhythmic events in patients with decompensated congestive heart failure. Annals of noninvasive electrocardiology : the official journal of the International Society for Holter and Noninvasive Electrocardiology, Inc, 7 3, 234-41

Burger, Andrew J; Burger, Mary R 2002. Nesiritide (Scios). IDrugs : the investigational drugs journal, 5 7, 703-9

Burger, Andrew J; Burger, Mary R; Aronson, Doron 2002. New therapies for the treatment of congestive heart failure. Drugs of today (Barcelona, Spain : 1998), 38 1, 31-48

Burger, Andrew J; D'Elia, John A; Weinrauch, Larry A; Lerman, Israel; Gaur, Abhishek 2002. Marked abnormalities in heart rate variability are associated with progressive deterioration of renal function in type I diabetic patients with overt nephropathy. International journal of cardiology, 86 2-3, 281-7

Burger, Andrew J; Horton, Darlene P; LeJemtel, Thierry; Ghali, Jalal K; Torre, Guillermo; Dennish, George; Koren, Michael; Dinerman, Jay; Silver, Marc; Cheng, Mei L; Elkayam, Uri 2002. Effect of nesiritide (B-type natriuretic peptide) and dobutamine on ventricular arrhythmias in the treatment of patients with acutely decompensated congestive heart failure: the PRECEDENT study. American heart journal, 144 6, 1102-8

Upalakalin, J Nalinee; Uhl, Lynne; Burger, Andrew J 2002. Mitral-valve-induced microangiopathic hemolytic anemia. Transfusion, 42 9, 1105

Aronson, D; Burger, A J 2001. Effect of beta-blockade on heart rate variability in decompensated heart failure. International journal of cardiology, 79 1, 31-9

Aronson, D; Burger, A J 2001. Effect of beta-blockade on autonomic modulation of heart rate and neurohormonal profile in decompensated heart failure. Annals of noninvasive electrocardiology : the official journal of the International Society for Holter and Noninvasive Electrocardiology, Inc, 6 2, 98-106

Aronson, D; Burger, A J 2001. Diabetic autonomic neuropathy: the clinical interpretation of improved technology. Diabetes technology & therapeutics, 3 1, 77-9

Aronson, D; Mittleman, M A; Burger, A J 2001. Role of endothelin in modulation of heart rate variability in patients with decompensated heart failure. Pacing and clinical electrophysiology : PACE, 24 11, 1607-15

Aronson, D; Mittleman, M A; Burger, A J 2001. Interleukin-6 levels are inversely correlated with heart rate variability in patients with decompensated heart failure. Journal of cardiovascular electrophysiology, 12 3, 294-300

Burger, A J; Aronson, D 2001. Blunted sympathetic response in diabetic patients with decompensated congestive heart failure. International journal of cardiology, 81 2-3, 243-9

Burger, A J; Aronson, D 2001. Activity of the neurohormonal system and its relationship to autonomic abnormalities in decompensated heart failure. Journal of cardiac failure, 7 2, 122-8

Burger, A J; Aronson, D 2001. Effect of diabetes mellitus on heart rate variability in patients with congestive heart failure. Pacing and clinical electrophysiology : PACE, 24 1, 53-9

Burger, A J; Charlamb, M J; Singh, S; Notarianni, M; Blackburn, G L; Sherman, H B 2001. Low risk of significant echocardiographic valvulopathy in patients treated with anorectic drugs. International journal of cardiology, 79 2-3, 159-65

Burger, A J; Elkayam, U; Neibaur, M T; Haught, H; Ghali, J; Horton, D P; Aronson, D 2001. Comparison of the occurrence of ventricular arrhythmias in patients with acutely decompensated congestive heart failure receiving dobutamine versus nesiritide therapy. The American journal of cardiology, 88 1, 35-9

Burger, M R; Burger, A J 2001. BNP in decompensated heart failure: diagnostic, prognostic and therapeutic potential. Current opinion in investigational drugs (London, England : 2000), 2 7, 929-35

Weigner, M J; Thomas, L R; Patel, U; Schwartz, J G; Burger, A J; Douglas, P S; Silverman, D I; Manning, W J 2001. Early cardioversion of atrial fibrillation facilitated by transesophageal echocardiography: short-term safety and impact on maintenance of sinus rhythm at 1 year. The American journal of medicine, 110 9, 694-702

Aronson, D; Burger, A J 2000. Gender-related differences in modulation of heart rate in patients with congestive heart failure. Journal of cardiovascular electrophysiology, 11 10, 1071-7

Burger, A J; Notarianni, M P; Aronson, D 2000. Safety and efficacy of an accelerated dobutamine stress echocardiography protocol in the evaluation of coronary artery disease. The American journal of cardiology, 86 8, 825-9

Burger, A J; Sherman, H B; Charlamb, M J 2000. Low incidence of embolic strokes with atrial septal aneurysms: A prospective, long-term study. American heart journal, 139 1 Pt 1, 149-52

Aronson, D; Weinrauch, L A; D'Elia, J A; Tofler, G H; Burger, A J 1999. Circadian patterns of heart rate variability, fibrinolytic activity, and hemostatic factors in type I diabetes mellitus with cardiac autonomic neuropathy. The American journal of cardiology, 84 4, 449-53

Burger, A J; Aronson, D 1999. Effect of vasoactive therapy on heart rate variability in patients with acutely decompensated congestive heart failure. The American journal of cardiology, 84 4, 476-8, A10

Burger, A J; Charlamb, M; Sherman, H B 1999. Circadian patterns of heart rate variability in normals, chronic stable angina and diabetes mellitus. International journal of cardiology, 71 1, 41-8

Burger, A J; Kamalesh, M 1999. Effect of beta-adrenergic blocker therapy on the circadian rhythm of heart rate variability in patients with chronic stable angina pectoris. The American journal of cardiology, 83 4, 596-8, A8

Burger, A J; Sherman, H B; Charlamb, M J; Kim, J; Asinas, L A; Flickner, S R; Blackburn, G L 1999. Low prevalence of valvular heart disease in 226 phentermine-fenfluramine protocol subjects prospectively followed for up to 30 months. Journal of the American College of Cardiology, 34 4, 1153-8

Burger, A J; Weinrauch, L A; D'Elia, J A; Aronson, D 1999. Effect of glycemic control on heart rate variability in type I diabetic patients with cardiac autonomic neuropathy. The American journal of cardiology, 84 6, 687-91

Burger, A J; Hamer, A W; Weinrauch, L A; D'Elia, J A 1998. Relation of heart rate variability and serum lipoproteins in type 1 diabetes mellitus and chronic stable angina pectoris. The American journal of cardiology, 81 8, 945-9

Burger, A J; Charlamb, M; Weinrauch, L A; D'Elia, J A 1997. Short- and long-term reproducibility of heart rate variability in patients with long-standing type I diabetes mellitus. The American journal of cardiology, 80 9, 1198-202

Burger, Andrew J.; Jadhav, Praveen; Kamalesh, Masoor 1997. Low Incidence of Cerebrovascular Events in Patients with Incidental Atrial Septal Aneurysm. Echocardiography (Mount Kisco, N.Y.), 14 6 Pt 1, 589-596

Jadhav, Praveen; Kamalesh, Masoor; Raju, Veena; Burger, Andrew J. 1997. Atrial Septal Aneurysm Does Not Predispose to Stroke in the Immediate Postoperative Period Following Cardiac Surgery. Echocardiography (Mount Kisco, N.Y.), 14 3, 251-256

Burger, A J; Kamalesh, M; Kumar, S; Nesto, R 1996. Effect of beta adrenergic receptor blockade on cardiac autonomic tone in patients with chronic stable angina. Pacing and clinical electrophysiology : PACE, 19 4 Pt 1, 411-7

Burger, A J; Jadhav, P; Kamalesh, M; Stubbe, I 1995. Absence of cerebrovascular events in a prospective study of coronary artery bypass patients with atrial septal aneurysms taking aspirin. The American journal of cardiology, 75 4, 305-8

Eyre, R C; Hurley, L J; Burger, A J; Lewis, K P 1995. Use of dynamic two-dimensional transesophageal echocardiography for renal cell carcinoma with cavoatrial tumor thrombus. Urologia internationalis, 54 3, 132-6

Kamalesh, M; Burger, A J; Kumar, S; Nesto, R 1995. Reproducibility of time and frequency domain analysis of heart rate variability in patients with chronic stable angina. Pacing and clinical electrophysiology : PACE, 18 11, 1991-4

Burger, A J 1994. On-site cardiac catheterization facilities and the use of coronary angiography after myocardial infarction. The New England journal of medicine, 330 4, 290

Connolly, L P; Hill, T C; Cohen, M C; Burger, A J 1994. Discordance of dual-isotope (hybrid) myocardial perfusion imaging results in patients who have undergone revascularization procedures. Clinical nuclear medicine, 19 11, 962-7

Kamalesh, M; Stokes, K; Burger, A J 1994. Transesophageal echocardiography assisted retrieval of embolized inferior vena cava stent. Catheterization and cardiovascular diagnosis, 33 2, 178-80

Burger, A J; Shubrooks, S J; Kamalesh, M 1993. TEE-guided percutaneous balloon mitral valvuloplasty. Catheterization and cardiovascular diagnosis, 30 2, 182

Cerel, A; Burger, A J 1993. The diagnosis of a pulmonary artery thrombus by transesophageal echocardiography. Chest, 103 3, 944-5

Kamalesh, M; Burger, A J; Shubrooks, S J 1993. The use of transesophageal echocardiography to avoid left atrial thrombus during percutaneous mitral valvuloplasty. Catheterization and cardiovascular diagnosis, 28 4, 320-2

O'Donoghue, M E; Dangond, F; Burger, A J; Suojanen, J N; Zarich, S; Tarsy, D 1993. Spontaneous calcific embolization to the supraclinoid internal carotid artery from a regurgitant bicuspid aortic valve. Neurology, 43 12, 2715-7

Kamalesh, M; Burger, A J 1992. Culprit coronary artery lesion. Lancet, 339 8787, 242

Kamalesh, M; Cerel, A; Burger, A J 1992. Management of atrial fibrillation. The New England journal of medicine, 327 14, 1031; author reply 1

Beaugerie, L; Burger, A J; Cadranel, J F; Lamy, P; Gendre, J P; Le Quintrec, Y 1991. Modulation of orocaecal transit time by hypnosis. Gut, 32 4, 393-4

Burger, A J; Peart, B; Freeman, D; Alfonso, G; Wheeler, W; Touchon, R 1991. The acute and chronic effects of G-lasing on femoral vein grafts in dogs. Angiology, 42 5, 372-8

Burger, A J; Peart, B; Jabi, H; Touchon, R C 1991. The role of two-dimensional echocardiology in the diagnosis of infective endocarditis [corrected] Angiology, 42 7, 552-60

Chertow, B S; Kadzielawa, R; Burger, A J 1991. Benign pleural effusions in long-standing diabetes mellitus. Chest, 99 5, 1108-11

Humbert, V H; Jabi, H; Burger, A J; Touchon, R C 1991. Late variation in ventricular function after myocardial infarction. Chest, 100 1, 28-33

Jabi, H; Burger, A J; Orawiec, B; Touchon, R C 1991. Late potentials in mitral valve prolapse. American heart journal, 122 5, 1340-5

Jabi, H; Burger, A J; Touchon, R C 1989. Left ventricular pseudoaneurysm after myocardial infarction. Postgraduate medicine, 85 8, 57-9, 62

Burger, A J; Mannino, S 1987. 5-Fluorouracil-induced coronary vasospasm. American heart journal, 114 2, 433-6

Burger, A J; Le Quintrec, Y 1985. [Psychiatry: why, how?] La Revue du praticien, 35 9, 499-503

Burger, A J; Messineo, F C; Schulman, P; Geller, D 1984. Mycotic aneurysm of the sinus of Valsalva due to Eikenella corrodens bacterial endocarditis. Cardiology, 71 4, 220-8

Burger, A J 1975. [Hemorrhagic rectocolitis. The psychic component and its interpretation] La Revue du praticien, 25 1, 39-43

Van der Walt, J J; Marcus, P B; De Wet, J J; Burger, A J 1973. Malacoplakia of the vagina. First case report. South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde, 47 30, 1342-4

BURGER, A J 1963. CARCINOMA OF THE PROSTATE. A REVIEW OF VARIOUS METHODS OF TREATMENT. South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde, 37 , 791-3

MARTINIE-DUBOUSQUET, J; BURGER-WAGNER, A; BURGER, A J 1963. [FAMILIAL DYSFACIOBRACHYCLINODACTYLIA.] Annales de chirurgie infantile, 4 , 281-90

BURGER, A J 1962. [Psychosomatic aspects of diarrhea.] La Revue du praticien, 12 , 199-203

BURGER, A J 1961. [Carcinoma of the prostate.] South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde, 35 , 1070-1

MARTINIE-DUBOUSQUET, J; BURGER, A J; BURGER-WAGNER, A 1958. [Osteochondritis & human types.] Vierteljahrsschrift für schweizerische Sanitätsoffiziere. Journal trimestriel des officiers suisses du service de santé. Rivista trimestrale degli ufficiali sanitari svizzeri, 35 3-4, 225-34

BURGER, A J S 1950. Ureterocele simulating bladder calculus. South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde, 24 16, 298-300

BURGER, A J . [Relaxation, psychotherapy & the problem of neuroses in the work of J.H. Schultz.] L' Evolution psychiatrique, 1, 163-73

Burger, A J; Fleury, R . [Glossodynia. Psychosomatic syndrome] Revue de stomatologie et de chirurgie maxillo-faciale, 67 1, 11-4

Burger, Andrew J . A review of the renal and neurohormonal effects of B-type natriuretic peptide. Congestive heart failure (Greenwich, Conn.), 11 1, 30-8

Hartnell, G G; Crenshaw, W B; Burger, A J; Hamer, A W . Percutaneous removal of a fully expanded Wallstent from the right ventricle with transesophageal echocardiography guidance. Journal of vascular and interventional radiology : JVIR, 7 3, 371-4

Wheeler, W E; Pace, C; Peart, B; Freeman, D; Alfonso, G; Burger, A J; Touchon, R . Effects of argon G-lasing on short-term patency of venous bypass grafts. Current surgery, 47 4, 265-6